Besides the typical symptoms associated with hyperthyroidism, patients with Graves' disease are also at risk for a number of different atypical symptoms.
Graves' disease is a condition of autoimmune hyperthyroidism, which typically causes one or more predominant symptoms related to excess thyroid hormone, such as nervousness, anxiety, and palpitations. Graves' disease can also cause extrathyroidal (away from the thyroid) manifestations, including pretibial myxedema, which primarily causes swelling and scaling of the lower legs, and the eye condition Graves' ophthalmopathy. In addition, Graves' disease can also cause several atypical symptoms such as erythema annulare centrifugum (EAC), vitiligo, hives, and weight gain. This article describes these atypical symptoms. It's important to recognize that these symptoms can be part of the Graves' disease spectrum rather than indications of a newly emerging illness.
DERMAL SYMPTOMS
Patients with Graves' disease can develop hypersensitivity reactions resulting in hives, urticaria (itching), and angioedema, a type of swelling that often occurs on the neck, face, or hands. A condition of urticaria-related angioedema can also occur. Although common allergens and insect bites are often implicated, the cause of the hypersensitivity reaction can't always be determined.
The condition erythema annulare centrifugum (EAC), which is classified as one of the figurate or gyrate erythemas (redness) can also occur. The rash in EAC is characterized by a scaling or non-scaling, reddened eruption which spreads from the edges outward while the center area clears. An exact trigger hasn't been determined for the hypersensitivity reaction in EAC. In scaling lesions, a trail of scales may follow the rash's periphery as it spreads. There are several varieties of EAC, some associated with itching and some with no symptoms other than rash. EAC tends to recur in times of stress and the condition may persist for several months to many years. Besides its association with Graves' disease, EAC may occur in patients with liver disease, hypereosinophilic syndrome, appendicitis, systemic lupus erythematosus (SLE) and Sjogren 's syndrome.
About 7 percent of patients with Graves' disease develop white or blanched patches of skin in a condition known as vitiligo.
Acropachy, a condition of soft tissue swelling that primarily affects the fingers and toes, causing a condition resembling elephantiasis, rarely occurs in patients with Graves' disease. Acropachy is most likely to occur in patients who have been treated with radioiodine ablation and also have pretibial myxedema. Acropachy is also considered a rheumatological disorder because it can cause an associated joint pain.
Skin and mucous membrane blisters and erosions can also occur in co-existing conditions of
autoimmune bullous skin disease, especially herpes gestationis, which can occur in pregnancy and during the postpartum period. In Graves' disease it may be confused with a anti-thyroid drug reaction.
METABOLIC SYMPTOMS
Hypoglycemia, a condition of low blood sugar, can occur as a transient condition in patients with Graves' disease. The hypoglycemia that occurs in patients with Graves' disease is caused by insulin antibodies that cause a condition of insulin autoimmune syndrome.
Hyperglycemia, a condition of elevated blood sugar can occur in patients with Graves' disease as part of a hyperglycemic hyper-osmolar state, similar to dehydration.
Weight gain occurs in 10-15 percent of patients with Graves' disease, usually younger patients. The reasons are unclear but appear to be due to inflammation and to deficiencies of free fatty acids. Sedentary changes related to fatigue may also be responsible.
Rhabdomyolysis, a potentially fatal condition of muscle destruction typically seen in cocaine and amphetamine overdoses, has been reported to rarely occur in patients with Graves' disease. In Graves' disease, rhabdomyolysis is caused by increasing energy consumption associated with depletion of muscle energy and muscle substrate stores.
Hypokalemia, a condition of low potassium, may occur in patients with Graves' disease, especially Asian males, and lead to thyrotoxic periodic paralysis. This condition leads to muscle weakness and temporary paralysis and tends to be exacerbated by the ingestion of alcohol and foods with a high sugar content.
CIRCULATORY CHANGES
A small number of patients with hyperthyroidism caused by Graves' disease are reported to have increased Factor VIII activity, which can cause increased clotting and cerebral venous thrombosis.
Patients with Graves' disease are more likely than other people to have antiphospholipid or anticardiolipin antibodies, which cause increased clotting. Antiphospholipid syndrome is the primary cause of miscarriages and strokes in young women.
NEUROLOGICAL CHANGES
A condition known as rapid consciousness disturbance, which is similar to dementia, can occur in Graves' disease, especially in elderly patients. Apathy is a similar presentation in the elderly Graves' patient.
Headache is a rare occurrence in Graves' disease and when it occurs it can be an early warning sign of cerebral venous thrombosis. Six reports of cerebral venous thrombosis have been reported in Graves' disease patients and appear to be related to recurrent inflammation. Of these six patients one was a male, and the other five were females, all of whom were using oral contraceptives.
Hashimoto's encephalopathy has been reported to occur in a small number of patients with Graves' disease, primarily middle-aged and elderly patients. Seizures and a condition of multifocal motor status epilepticus have also been reported in a small number of patients with Graves' disease.
EYE CHANGES
Besides the typical symptoms of thyroid eye disease (TED) associated with either abnormal thyroid hormone levels or the autoimmune process, a small number of patients with Graves' disease may develop a temporary condition of unilateral edema, affecting the upper eyelid of only one eye. Unilateral edema is a sign of hyperthyroidism and typically resolves as thyroid hormone levels return to the normal range.
The copyright of the article Atypical Graves' Disease Symptoms in Thyroid Disorders is owned by Elaine Moore. Permission to republish Atypical Graves' Disease Symptoms in print or online must be granted by the author in writing.
Is this Graves' Disease is resemble with vitiligo. actually vitilgo has sub
catagorized in five types. i.e Localized Vitiligo: Focal pattern
vitiligo, Segmental pattern vitiligo Generalized Vitiligo: Acrofacial vitiligo, Vulgaris Vitiligo, Universal vitiligo This
info is read from the site http://www.antivitiligo.com
Feb 10, 2009 12:28 AM
Guest :
Thanks so much for your article. I had a brain bleed a year and a half ago
after having my baby and just recently was Dx with Graves. Have had really
bad headaches since then. May I have permission to print this and take it
to my Neuro doc? walerius34@yahoo.com
Feb 10, 2009 9:55 AM
Elaine Moore :
Hi, Feel free to share this information with your doctor. Best, elaine
Jul 5, 2009 9:05 AM
Elaine Moore :
Hi, I'm glad you found this article helpful. Being on the optimal dose
and type of replacement hormone may help reduce some of your symptoms. Be
sure your doctor is testing FT4 and FT3 levels to help determine your
optimal dose. I have more information on my website, www.elaine-moore.com.
Best, Elaine
Aug 17, 2009 3:36 PM
Elaine Moore :
Hi, Were the antibiotics you were given penicillin derivatives like
amoxicillin? Some of us with Graves' disease are allergic to penicillin and
develop hives from it. This could be your problem, and it usually occurs
the second time you use this type of med. Hives can also develop from
Tapazole if the dose is too high. Your starting dose should be between
10-30 mg daily and as soon as your FT4 level comes into the reference range
the dose should be reduced. Diphenhydramine (Benadryl) or hydroxyzine
(Vistaril) are often used for hives, although if it's from penicillin
you'll see resolution a while after stopping meds. Best to you, Elaine
Sep 18, 2009 3:22 PM
Guest :
Elaine...I just read your August 17 response and saw mention of allergies
to antibiotics. I was diagnosed with Graves in 06, medicated and soon
became hypo. In remission for 6 months then levels went crazy...T3 Free of
1021/TSH .01. Did not want thyroid taken out. Medicated again. Hypo
again. Then remission for 2 years. August last year I had to take
Amoxicillan for an ear infection and got serum sickness. They switched me
to Bioxin and I had side effects. Most recently, I was given Levaquin for
another ear infection. My legs were killing me so I stopped it. Later
that week I started having rapid heart...T3, Free is now 836, TSH .01, TSI
155, Thyroglobuin Anti 127, Peroxidase 37, T3total 376, T4free 2.9, T4
total 16.0. Have you seen anyone's Graves triggered by antibiotics?
Thinking about getting thyroid out, any thoughts? Thanks!
Sep 22, 2009 12:16 PM
Elaine Moore :
Hi, Often, antibiotics trigger autoimmune diseases, including Graves'
disease, especially when we're allergic to specific antibiotics.
Usually, people become hypothyroid when they're kept on a dose of
anti-thyroid drugs that's too high. This happens when doctors try to see a
rise in TSH. Normally, in Graves' disease TSH stays very low until
remission occurs or the ATD dose is too high and causes hypothyroidism. The
lowest doses of meds needed to keep FT4 at least at mid-range should be
used and gradually reduced over time until remission occurs. With meds used
correctly most everyone can achieve remission. The highest rates of
remission are seen in people using low-dose ATDs long-term (average 4
years). If hypothyroidism is allowed to develop it sets everything back as
it encourages thyroid antibody production. If you're properly
medicated and can't achieve remission thyroidectomy is a good option
although you'd still have to work on healing your immune system. Best, Elaine
Oct 2, 2009 3:07 AM
Guest :
Hi Elaine,
Good Article. I spent nearly 6 months with worsening
health & saw 3 doctors before an ER doctor finally figured out my
problem. I had many blood test done months prior to this & yet nothing
stood out to them. I had spent the last 5 months with waking up mid sleep
not being able to roll over on my side in bed due to lost muscle strength
from my neck down. It wore off by morning usually so I pushed it off as a
poor diet (250lbs 5' 8" male) & kept going on with my way every
time it happened.
Then it kept coming back more frequently.
Now, every night I couldn't get out of bed to go to the washroom or even
blow my nose. I had no chest or lung muscles to even sneeze, & it hurt
when I did sneeze. Finally I knew I had minor wonky heart beat but nothing
major growing up. I then started to develop very huge heart palpitations
& breathing problems every so often. Finally, around 4am 3 weeks ago
& was rushed to Emerge. I was Diagnosed with Thyrotoxic Periodic
Paralysis + Graves Disease. I had potassium levels of 1.6 when normal is 5
& they get worried around 3. my heart was doing weird things while in
the ER & I was passing out repeatedly with nearly no pulse then bounced
around again. I had many ECG's done & they said that I needed potassium
QUICK because levels that low really affect the muscles in the heart &
could kill me quite easily. I had a central line put in through my groin up
to my chest which was connected to bags of Potassium chloride (KCL) as well
as 50mg liquid potassium to drink.
Now Potassium Chloride is
something used in lethal injections so it has to be monitored regularly
& given in small doses. So too much potassium can stop your heart &
too little of potassium can.... stop your heart... Be careful & always
consult with your doctor or in my case endocrinologist.
They
finally concluded that hyperthyroidism & my severe sweating issue found
that I was sweating so much, the cells were pushing the potassium out &
depleting my body on a regular basis. Normally sweating isn't a huge factor
but i'm a rare case they said. My thyroid was being attacked as an auto
immune disease & over functioning, I've always been large my whole
life, never able to lose it (which is opposite to the studies of
hyperthyroidism) & now they have me on Tapazole to slow down the
thyroid & Propranolol to use as a beta blocker to keep the potassium
away from the cells.
The next step in all this is radioactive
iodine to kill the thyroid...then Synthroid :'(
Oct 2, 2009 9:44 AM
Elaine Moore :
Hi, I'm glad your thyrotoxic periodic paralysis and Graves' disease
were discovered. I have information on TPP in my book on Graves'
disease.
You might want to visit my website at
www.elaine-moore.com. It's important to realize that Graves' is a
self-limiting autoimmune disorder. Radioiodine is not always the desired
treatment option. While it destroys your normal thyroid gland and causes
hypothyroidism, it can lead to other conditions including thyroid eye
disease, excessive weight gain, and other autoimmune disorders.
Medications such as methimazole are used to lower thyroid hormone levels
and help the immune system heal. This helps stop thyroid antibody
production, which is the cause of Graves' disease. In GD, thyroid
antibodies cause the immune system to produce TSI antibodies. TSI order
thyroid cells to produce excess thyroid hormone. The goal here is to reduce
TSI production. Radioiodine causes a dramatic increase in TSI.Best, Elaine
Sep 25, 2006
